Cycle 1
Health 2025-09-04 · Fire 2025-09-04
9 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Montrose, PA
Meadow View Rehabilitation & Healthcare Center
3-star overall rating with 3-star inspections with $105,587 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
225 Park Street, Montrose, PA
(570) 278-3836
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
63
Certified beds
Average residents
57
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Century Healthcare
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.60
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.56
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.69
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
2.85
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.15
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
2.61
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.59
CMS adjusted RN staffing hours
Adjusted total hours
2.83
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,575
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.30
Composite VBP score used to determine payment impact.
Payment multiplier
0.9841
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.75
Baseline 19.66% · Performance 20.16% · Measure score 2.75 · Achievement 2.75 · Improvement 0
Healthcare-associated infections
5.59
Baseline 5.20% · Performance 6.17% · Measure score 5.59 · Achievement 5.59 · Improvement 0
Total nurse turnover
0.71
Baseline 48.72% · Performance 60.78% · Measure score 0.71 · Achievement 0.71 · Improvement 0
Adjusted total nurse staffing
1.48
Baseline 3.08 hours · Performance 3.50 hours · Measure score 1.48 · Achievement 1.48 · Improvement 1.05
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.64% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 73 · Observed rate 10.96% · Lower 95% interval 7.62% |
| Discharge to community | 37.5% |
50.57%
13.1 pts worse
|
Worse than the National Rate · Eligible stays 66 · Observed rate 34.85% · Lower 95% interval 29.72% |
| Medicare spending per beneficiary | 0.69 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 62.5% |
95.27%
32.8 pts worse
|
Numerator 30 · Denominator 48 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 48 |
| Discharge self-care score | 37.14% |
53.69%
16.5 pts worse
|
Numerator 13 · Denominator 35 |
| Discharge mobility score | 28.57% |
50.94%
22.4 pts worse
|
Numerator 10 · Denominator 35 |
| Pressure ulcers or injuries, new or worsened | 4.17% |
2.29%
1.9 pts worse
|
Numerator 2 · Denominator 48 · Adjusted rate 3.36% |
| Healthcare-associated infections requiring hospitalization | 6.17% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 35 · Observed rate 0% · Lower 95% interval 3.53% |
| Staff COVID-19 vaccination coverage | 61.29% |
8.2%
53.1 pts better
|
Numerator 38 · Denominator 62 |
| Staff flu vaccination coverage | 41.1% |
42%
0.9 pts worse
|
Numerator 30 · Denominator 73 |
| Discharge function score | 34.29% |
56.45%
22.2 pts worse
|
Numerator 12 · Denominator 35 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 19.35% |
25.2%
5.8 pts worse
|
Numerator 6 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.7
0.4 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.2
0.3 pts worse
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 86.9% |
86.9%
About the same
|
93.4%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 89.1% · Q2 93.2% · Q3 80.5% · Q4 84.4% · 4Q avg 86.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.9% |
93.5%
0.4 pts better
|
95.5%
1.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.2%
3.2 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.7% |
6.5%
5.2 pts worse
|
11.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 5.1% · Q3 0.0% · Q4 27.9% · 4Q avg 11.7% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
6.5%
1.2 pts better
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 12.1% · Q3 2.7% · Q4 0.0% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.5% |
19.9%
4.6 pts worse
|
19.6%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 17.1% · Q3 27.0% · Q4 29.3% · 4Q avg 24.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.1% |
18.7%
6.6 pts better
|
16.7%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 10.3% · Q3 14.8% · Q4 13.3% · 4Q avg 12.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.6% |
19.6%
6 pts better
|
16.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.6% |
18.3%
6.7 pts better
|
14.9%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 11.4% · Q3 10.8% · Q4 7.3% · 4Q avg 11.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.9%
0.3 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.4% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.7%
0.5 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.3% |
26.4%
0.9 pts worse
|
19.8%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 31.7% · Q3 26.0% · Q4 29.6% · 4Q avg 27.3% |
| Percentage of long-stay residents with pressure ulcers | 0.5% |
5.3%
4.8 pts better
|
5.1%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 37.6% |
68.9%
31.3 pts worse
|
81.7%
44.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 43.8% · Q2 32.8% · Q3 32.2% · Q4 43.4% · 4Q avg 37.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.2% |
9.8%
1.6 pts better
|
12.0%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.2% · Observed 7.1% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.6% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 21.7% |
68.7%
47 pts worse
|
79.7%
58 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 21.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.6% |
23.1%
6.5 pts worse
|
23.9%
5.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.6% · Observed 21.4% · Expected 17.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-07 · Fire 2024-11-07
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-12-14 · Fire 2023-12-14
10 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-09-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-20
E · Potential for more than minimal harm
2025-09-04
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2026-01-20
F · Potential for more than minimal harm
2024-11-07
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-11-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-10
E · Potential for more than minimal harm
2023-12-14
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-01-16
E · Potential for more than minimal harm
2023-12-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-16
E · Potential for more than minimal harm
2023-12-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-16
E · Potential for more than minimal harm
2023-12-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-01-16
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-04
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-10-02
E · Potential for more than minimal harm
2025-09-04
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-10-02
E · Potential for more than minimal harm
2025-09-04
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-10-02
D · Potential for more than minimal harm
2025-09-04
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-10-02
D · Potential for more than minimal harm
2025-09-04
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-10-02
D · Potential for more than minimal harm
2025-05-13
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-03-19
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-05-13
D · Potential for more than minimal harm
2025-03-19
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-05-13
D · Potential for more than minimal harm
2025-03-19
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-05-13
E · Potential for more than minimal harm
2024-11-07
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-11-07
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-11-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-11-07
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-11-07
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-11-07
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-07
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-03-15
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2024-05-08
D · Potential for more than minimal harm
2024-03-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-08
D · Potential for more than minimal harm
2024-03-15
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-05-08
D · Potential for more than minimal harm
2024-03-15
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-05-08
G · Actual harm
2023-12-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-08
E · Potential for more than minimal harm
2023-12-14
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-02-07
E · Potential for more than minimal harm
2023-12-14
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-05-08
E · Potential for more than minimal harm
2023-12-14
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-02-07
E · Potential for more than minimal harm
2023-12-14
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-03-15
D · Potential for more than minimal harm
2023-12-14
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-02-07
D · Potential for more than minimal harm
2023-12-14
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-02-07
D · Potential for more than minimal harm
2023-12-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-02-07
D · Potential for more than minimal harm
2023-12-14
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-03-15
D · Potential for more than minimal harm
2023-12-14
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-02-07
Penalties and ownership
What sits behind the stars
$105,587
2023-12-14
Fine
Fine · fine $105,587
Fine
$0
2023-12-14
Payment Denial
Payment Denial · denial start 2024-03-06 · 63 days
63 day denial
Ownership
Century Iii Pennsylvania Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Berdugo, Shai
5% Or Greater Indirect Ownership Interest · Individual
Berdugo, Shai
Operational/Managerial Control · Individual
Century Iii Tbd Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Cundey, Chelsey
Operational/Managerial Control · Individual
Klein, Efraim
5% Or Greater Indirect Ownership Interest · Individual
Klein, Efraim
Corporate Officer · Individual
Kulanu Oc Trust
5% Or Greater Indirect Ownership Interest · Organization
Ralley LLC
Operational/Managerial Control · Organization
Speicher, Joseph
Operational/Managerial Control · Individual
Nearby options
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Barnes-Kasson County Hospital
Susquehanna, PA
2-star overall rating with 3-star inspections with $42,289 in total fines with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Vestal Park Rehabilitation And Nursing Center
Vestal, NY
2-star overall rating with 1-star inspections with 12 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Willow Point Rehabilitation And Nursing Center
Vestal, NY
1-star overall rating with 1-star inspections with $166,364 in total fines with 6 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
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